Thyroid Disease Testing

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Abbreviations INDICATIONS FOR TESTING

T3 Triiodothyronine  Signs or symptoms of thyroid disease (eg, heat or cold intolerance, unexplained weight
T4 Thyroxine loss or gain, depression)
TPO Thyroid peroxidase  Goiter on physical exam
TRAb Thyroid stimulating hormone  Age >60 yrs (screening indicated)
receptor antibody  Increased risk of hypothyroidism, eg, family history of thyroid disease, head or neck
TSH Thyroid stimulating hormone irradiation (aggressive case finding should be considered)
TSI Thyroid stimulating immunoglobulin

ORDER
Low TSH Thyroid Stimulating Hormone with Reflex High TSH
to Free Thyroxine

Normal TSH and

Suggests Suggests
free T4
hyperthyroidism hypothyroidism

Thyroid disease unlikely

Low free T4 Normal free T4 High free T4

Low free T4 Normal free T4 High free T4

CONSIDER CONSIDER
CONSIDER
 Primary hypothyroidism  Thyroid hormone
 Subclinical
CONSIDER CONSIDER  Ablated thyroid hypothyroidism
resistance
CONSIDER
 Central  Subclinical  Hashimoto thyroiditis  TSH resistance
 Overt (primary)  Transient thyroiditis
hypothyroidism hyperthyroidism  Transient (subacute)  TSH-secreting
hyperthyroidism  T3 hypothyroidism
 Severe illnessa  Drug interference  Graves disease
thyroiditis pituitary adenoma
 Nonthyroidal  Rare pituitary  Central
illness syndrome conditions hyperthyroidism

CONSIDER CONSIDER
CONSIDER
Triiodothyronine, Total
 Thyroid Stimulating Immunoglobulin Thyroid Antibodies
Continued suspicion (Total T3)
 Thyroid Peroxidase (TPO) Antibody
of hyperthyroidism
 Thyroid Stimulating Hormone Receptor
Antibody (TRAb)
ORDER Positive
Triiodothyronine, Total Low T3 Normal T3
(Total T3) TSI positive TSI Ab negative
TPO Ab positive/negative TPO Ab negative
TRAb positive/negative Autoimmune
Normal total T3 High total T3 b thyroid disease
Appropriate clinical signs Hypothyroidism
Toxic nodules T3 hypothyroidism
likely unlikely

Hyperthryoidism unlikely T3 hyperthyroidism

CONSIDER (T3 toxicosis) Graves disease
a
Subclinical hyperthyroidism Thyroid function testing is not generally recommended for severely ill or hospitalized individuals.
b
Clinical signs include Graves ophthalmologic disease and diffuse thyroid gland enlargement.

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